Blog article: The Shoulder and Elbow in the Overhead Athlete Part II: Common Shoulder and Elbow Injuries and How To Avoid Them

The Shoulder and Elbow in the Overhead Athlete

Part II: Common Shoulder and Elbow Injuries and How To Avoid Them

In part 1, the biomechanics of each phase of the baseball pitch were reviewed along with forces placed on the shoulder and elbow. It is clear that throwing a baseball is an extremely aggressive and violent act in which extreme forces and ranges of motion are placed on the shoulder and elbow. In part 2 I will review the characteristics of a pitcher, common injuries in these athletes and how you can avoid them.

Physical Characteristics of a pitcher’s dominant arm vs non-dominant arm:

Range of motion disparity

  • dominant shoulder has excessive external rotation and limited internal rotation

 

Laxity

  • excessive glenohumeral capsule laxity, which is an acquired laxity from repetitive strain

 

Osseous adaptations

  • Increase shoulder retroversion (rotated backwards)

 

Strength

  • weak external rotators, strong internal rotators
  • strong scapular protractors and elevators

 

Posture:

  • scapula protracted, anteriorly rotated at rest
  • increased scapular upward rotation during abduction of the shoulder

 

Glenohumeral Internal Rotation Deficit (GIRD)

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This develops throughout a season or over years of repeated throwing and is characterized by a significant loss of internal rotation of the shoulder. Many pitchers have a natural loss of internal rotation which is usually off-set by an increase in external rotation range of motion. GIRD becomes an issue when there is a larger loss of internal rotation than there is a gain in external rotation. If not addressed, this puts the athlete at increased risk of developing some of the shoulder injuries that will be discussed below. Also, most pitchers maintain a very similar total range of motion in the dominant and non-dominant shoulders but at times an uncompensated GIRD can lead to differences of 10-15 degrees or more.

As discussed in the previous article, most injuries occur during the late cocking, acceleration and the deceleration phases of the pitch.  To get a better understanding of why these injuries occur during specific phases, review part I to get an idea of the stresses at the shoulder and elbow during each phase.

 

Late Cocking Phase Injuries

Anterior Glenohumeral Instability. This is an umbrella diagnosis that can include the following:

 

SLAP Lesions:  Injury to the upper labrum of the shoulder. There are 4 common types. Types II and IV involve the origin of the long head of the biceps. When the biceps anchor is involved there tends to be an increase in shoulder instability. Type II is most commonly seen in the overhead athlete in which the “peel back” forces on the biceps tear the labrum and the biceps anchor.

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Bankart Lesion: Injury to the anterior-inferior (front-bottom) part of the labrum. The head of the humerus will translate forward in the shoulder socket due to this injury.

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Biceps Long Head Instability: When the shoulder is in the cocked position (90 degrees of abduction and external rotation) the long head of the biceps is placed anteriorly to the head of the humerus. With repetition of this movement and if the athlete has GIRD or a labrum lesion, the biceps tendon takes one excessive strain due to anterior movement of the humeral head. This leads to further instability. It can initially present as tendonitis and develop into tears, ruptures.

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Internal Impingement, Subacromial Impingement: Anterior instability leads to compression of the posterior and/or superior rotator cuff tendons. It can also include compression of the superior labrum.

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Acceleration Phase Injuries

UCL Injury: Sprain or tear of the ulnar collateral ligament of the elbow due to violent extension, valgus force, pronation and a traction force on the elbow. Athletes usually feel a pop followed by immediate intense pain.

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Valgus Extension Overload:  This injury is exclusive to overhead athletes and is caused by repeated forceful hyperextension and valgus stress of the elbow. There is compression of the lateral part and distraction of the medial elbow. This injury is characterized by soft tissue swelling, development of osteophytes (bony overgrowth) in the elbow and at times fractures of the elbow can occur.

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Little League Elbow:  This is characterized by the same forces on the elbow seen in valgus extension overload but occurs in preadolescents. It can lead to changes in the growth of the medial epicondyle of the humerus, tears of the wrist flexor tendons or even stress fractures of the humerus growth plates.

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Deceleration Phase Injuries: These include all of the acceleration phase injuries along with rotator cuff tendonitis and tears.

 

So now you know all of the bad things that can happen to your shoulder or elbow with repeated pitching. Did it make you want to do everything that you can to prevent these from happening?…. I hope so.

I am going to go over some things that I do with my patients in therapy, along with our clients at SPI to help decrease their risk of developing one of these shoulder or elbow injuries.

 

Posterior Shoulder Mobility

As described above, anterior instability leads to many shoulder injuries. That’s why it is extremely important to maintain good mobility and soft tissue quality of the posterior shoulder to prevent excessive anterior movement of the humeral head.

 

Modified Sleeper Stretch

This works on improving internal rotation and stretching the posterior cuff muscles. The traditional sleeper stretch involves the body and arm being at a 90 degree angle, this however reinforces the compression of the tendons in the shoulder. The modified stretch has the body rotated back at 20-30 degrees to avoid this.

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Modified Cross Body Stretch: The athlete stabilizes the scapula on their side and restricts external rotation at the elbow.

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Posterior Cuff Mobilization: Using a lacrosse ball the athlete mobilizes the posterior rotator cuff. They can perform circles using their trunk to move while maintaining pressure, they can also perform active shoulder movements.

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Thrower’s Ten / Advanced Thrower’s Ten: We utilize these shoulder strengthening programs developed by Kevin Wilk; a sports physical therapist who works with Dr. James Andrews and many MLB players to develop shoulder strength, stability and prevent injury. These exercises strengthen the shoulder while challenging the core by performing most on a stability ball.

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These are just a few examples of what we do. There’s a lot of ways we work on the shoulder and elbow using techniques proven through sports medicine research. I can’t give away all of the goods. I can give you an idea of what else we work on….. CORE AND POSTERIOR CHAIN.

Some tips for decreasing injury risk while training:

1. don’t do overhead presses – they reinforce the shoulder impingement mechanism

2. limit back squats – or if you do back squats, use a safety bar to prevent anterior shoulder strain. I prefer front squats or hip thrusts.

3. limit bench pressing – it “locks down” your shoulder blades. Do pushups instead, there’s a ton of ways to progress pushups to make them more challenging.

 

What else can you do to help prevent injury?….. don’t throw year round. Nowadays we see athletes playing in leagues for almost the entire year!  This continues to be the number one risk factor for developing injuries.

If you would like to learn more on how you can prevent shoulder and elbow injuries, properly strengthen and stabilize your shoulders and train like the pros then contact mike@spiutica.com

Blog Post – Has Human Performance Passed Human Evolution?

Has Human Performance Passed Human Evolution?

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This past weekend I had the opportunity to work along side an Orthopedic Surgeon who specializes in Sports Medicine with more years of experience than he would like me to mention in this blog post. I always look forward to these times as he is a great teacher and I get 3+ hours to pick his brain.

One topic that we spoke of was the rise in shoulder and elbow injuries for baseball players, specifically pitchers. I told him my hypothesis (and not mine alone) that the increase in the velocity of the fast-ball over the past decade and the rise in injuries is a correlation that cannot be ignored. Even with the advancement in injury prevention and pitch count etc. we usually will not see a significant change until the younger generations become of age to sustain a possible injury.

With the emergence of concussions being a significant problem in the media and the rise in shoulder and elbow injuries for major league baseball, one injury that has taken a back seat in recent years are ACL tears.

ACL tears have become a common theme in athletics and specifically female athletics. Female athletes have a 4-6x greater chance of tearing an ACL then their male counterparts and about 1 in 20 female collegiate athletes will undergo an ACL injury.

So why is there not a huge out-cry to stop female athletics like there is to institute pitch count rules or remove hitting in football? Surely these numbers are indicative of an epidemic. One thing is that we have gotten really good at fixing ACL’s and they are not career ending like they were 20 years ago.

fig-3What do we know?

  1. We know that like the ulnar collateral ligament of the elbow there has been a rise in ACL injuries over the past ten years.
  2. We have many theories as to why there is an increase in ACL injury in the male and female athlete but not one thing is certain.
  3. 70% of ACL injuries are non-contact.

Lets take a look at that last statistic. 70% of the injuries are non-contact. Doesn’t that seem a little funny? 30% of the injuries are relatively unpreventable with contact sports being the way they are but 70% come from performing normal athletic activities such as running, cutting and jumping.

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So this leads us to the title of this article: Has Human Performance Passed Human Evolution. If a possible reason for the increase in UCL injuries of the elbow is due to the increase in velocity of throwing, is it reasonable to assume that in sports such as football, basketball and soccer where the athletes are getting bigger, faster and stronger has our muscular strength increased so much that our ligaments cannot withstand the stress put on them with athletic activity? And I’m not speaking of a muscular imbalance here. I have some highly skilled and significantly strong athletes who still manage to tear their ACL.

Where do we go from here? Fortunately there is a significant amount of research out there on what works and what doesn’t as far as ACL injury prevention. Our goal at SPI is to implement these specific exercises and training techniques into our programming for our male and female athletes. To find out more information about our ACL injury prevention programs contact us at info@spiutica.com for us to speak to your organization and show you how to implement these exercises to reduce risk of injury.

Blog Article – Hip Pain in the Athlete

Hip Pain In The Athlete 

Football player most stressed joints

As a physical therapist and sports performance trainer I get to work with a good deal of athletes. One common issue that I have been coming across lately is hip pain.

Hip pain can have many different causes but most commonly there’s soft tissue (muscle, tendon, cartilage) involvement.  Lately I am seeing a major contributor to these patients and clients coming in the door with hip pain, and that is muscle imbalances. 

Too many athletes these days are “living in an anterior pelvic tilt”. I am seeing this issue in so many of my athletes. Anterior pelvic tilt can cause pain in the front, back or in both areas of the hip. Anterior pelvic tilt is caused by tight hip flexors and lower back along with weak abdominals and glutes. This presentation is called pelvic or lower crossed syndrome.

lower-cross-syndrome

Anterior pelvic tilt puts the athlete at increased risk for common sports injuries such as groin strains, hip flexor tendonitis, hip impingement. It can also lead to issues above and below the hip such as low back pain, IT band syndrome and increase risk for knee injuries.

I always stress to all of my athletes that they need to have a strong core and posterior chain to become elite. This will help even out these “imbalances”. I work on these areas in every single session. I used to find it shocking that many of my athletes (even college level) can’t do a proper plank, squat or lunge without some sort of deviation. I now know to look for these deficits right away and to work on correcting before it becomes a big issue.

Here are some examples of what we have our clients do:

 

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one of the best ways to strengthen your glutes and hamstrings, they have been found to activate your gluteus maximus more than traditional back squats

 

TRX Deep Squat Lat Stretch

 

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great way to work on hip mobility while stretching out the back, adding in     diaphragmatic breathing in the squat position will also engage your core

 

 

 

 

Half Kneeling Hip Flexor Stretch 

 

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an effective way of lengthening the hip flexors, make sure not too “over-stretch” or the muscle will increase in tone due to excessive strain.  Tighten up your glutes on the down leg and you’ll really feel it. As shown in the picture, adding an overhead kettle bell press hold will also engage the core and shoulder stabilizers

 

 

Dead Bug with Band Pull Down

 

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A great progression of the traditional dead bug exercise, really works the lower abdominals and adding in the band pull activates your lats and shoulders, key is maintaining the low back flat against the ground while kicking out, it’s harder than it looks

 

email mike@spiutica.com if you are having sports related hip pain or if you think these exercises look cool and want to become a bad-ass athlete.

Speed and Explosion for Athletes

 

Over the decades numerous scientists and coaches alike have been researching the best ways to improve an athlete’s sprint acceleration, overall speed, and their optimal levels of explosion. The following research will summarize and explain the relationship of maximum strength, power or speed strength, Olympic lifts, plyometric training, resisted sprints, and speed sprints and all of their respective influence on sprint acceleration (Henricks, 2004.)

Overall when strength and power are both increased in an athlete their acceleration performance will also increase (Henricks, 2004.) Each day that goes on scientists and coaches are looking for the newest, or best ways to increase their respective athlete’s acceleration whether it is a field athlete or track specific sprinting athlete.

It was stated that muscular peak force specifically during concentric contractions in relation to body weight can lead to improvements in acceleration (Henricks, 2014.)

When looking specifically at track sprinters research has showed that the initial three steps of acceleration are related to propulsive forces and concentric muscle contractions (Henricks, 2014.) This research shows that if athletes specifically train to increase the selected muscles that have concentric contractions with the initial steps of acceleration then their sprint acceleration overall will improve in terms of performance (Henricks, 2014.)

Strength and power are two of the most sought after components of strength and conditioning by coaches, trainers, and athletes alike. Strength is defined as the ability to exert maximum force, while power is defined as maximum force applied with maximum velocity over a full range of motion (Henricks, 2014.) Despite strength being extremely important with athletics, power is the most crucial aspect for acceleration with sprinting activities along with jumping activities (Henricks, 2014.) This shows that power development specifically may be most important for the majority of sporting activities as long as strength levels are already established in terms of their appropriate levels for the specific sport (Henricks, 2014). This further illustrates the importance of explosive power based exercises importance in terms of sports specific performance.

As research shows force/strength and power have an inverse relationship. What exactly does this mean? Force and velocity will increase/decrease in an opposing relationship. More specifically as stated in the research as velocity of the movement increases so does the muscle shortening also known as the concentric contraction of the muscle and therefore the force of the movement generated decreases (Henricks, 2014.) Another example of how this concept is illustrated as an inverse relationship is when resistance increases that ability of the force generate during the concentric contraction is increased while at the same time the velocity decreases (Henricks, 2014.)

This relationship is referred to as the force-velocity relationship (Henricks, 2014.) This states that power output varies in terms of the load applied to the movement (Henricks, 2014.) A real world example of this in the strength and conditioning world is when looking at kettlebell or Olympic lifting exercises. The heavier or larger the load the more the velocity of the movement decreases.

This research specifically divided the qualities of strength into the following; maximum strength, power or speed strength, plyometric, and sports specific strength such as resisted and non-resisted sprint training (Henricks, 2014). The research applied these qualities of strength and their relation to acceleration, peak power, peak force, peak velocity, rate of force development and the stretch shortening cycle (Henricks, 2014).

For a coach  designing a strength and conditioning program with speed development as the focal point the first thing to address is whether or not the athlete has sound baseline levels of strength and stabilization as indicated in the National Academy of Sports Medicine Optimum Performance Training Model (Clark & Lucett, 2008.) Proper core and balance stabilization exercises can help reduce the time between the eccentric and concentric contraction phases as seen in the stretch-shortening cycle (Clark & Lucett, 2008.) It is seen often where coaches will immediately place athletes into speed and explosion style training and this can often lead to injury especially in the youth athletic population (Dintiman & Ward, 2009.) Especially with young athletes prior to beginning any speed, explosion, and power training baseline levels of stabilization, strength, and flexibility should be obtained using body weight calisthenics, a baseline flexibility protocol, all the while keeping the training fun (Dintiman & Ward, 2009.)

As long as baseline strength and stabilization levels are determined to be sufficient enough to continue on with sport specific speed, explosion, and power training then the athlete can partake in a program looking for speed development. All types of speed development training were looked at such as power lifting, Olympic lifting, resisted and non-resisted sprint training, and plyometric training in this research. It was determined that overall all types of training can be positive in terms of increasing an athlete’s speed development and power (Henricks, 2014.). Even strength training alone can still contribute to gains in speed development with exercises such as the deadlift as it utilizes the concept of triple extension which is crucial to develop with sprinting and speed training (Dintiman & Ward, 2009.)

Of course specific variables need to be taken into consideration with each different sport, the season the athlete is in, previous injury history and many others when designing a productive speed development program. Even detailed aspects such as what plane of motion the exercise is occurring can help further contribute to strength gains (Henricks, 2014.) Most research with speed development training programs have to do with the athlete being on bilateral lower extremities in the vertical plane but recent research showed that further speed development can happen when training athletes unilaterally in the horizontal plane (Henricks, 2014.) This type of training in an eight week program showed a 2.6% increase in sprint acceleration when compared to bilateral vertical plane training (Henrick, 2014.)

So for the coaches and athletes out there, do not always stick to your squat jumps, box jumps, and vertical jumps, but also look to exercises in the horizontal plane on one leg such as lateral bound exercises, and even plyometric skater squat variations.

The old concept of taking what is useful and rejecting what is useless is most definitely applicable when developing strength and conditioning programs specifically looking for sprint acceleration improvements. In this case almost all training styles can increase one’s sprint acceleration and speed development but the difficulty may lie in terms of when to implement what movements and programs. As seen with chronic repetitive overuse injuries as mentioned by the National Academy of Sports Medicine (Clark & Lucett, 2008) one style of training used too much can lead to injury. This means it is essential to use concepts of specificity, and periodization when designing a strength and conditioning program related to speed development and sprint acceleration (Dintiman & Ward, 2009.)

Cycling in and out of an example progression such as starting with a stabilization based program utilizing a great deal of balance and core training, then moving to a strength based program using exercises such as power lifting techniques like the deadlift then moving to a power based program using Olympic lifting, plyometric training, and reactive training on both single and both extremities is an excellent general progression (Clark & Lucett, 2008.) Once an athlete has mastered this progression in their initial phases of advanced strength and conditioning then all phases of this style of training can be incorporated year round as long as depending on what phase of the athletic season an athlete is in dictates what the main emphasis is.

A thorough strength and conditioning program will use both research and practice based knowledge, multiple styles of strength and power training, along with taking the individual athlete’s physiological background all into consideration.

Need some help with improving your athlete’s speed and explosion? Contact info@spiutica.com and schedule are free consultation/assessment with one of our skilled coaches!

References

Clark, M., & Lucett, S. (2008). NASM essentials of personal fitness training (3rd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Dintiman, G. B., & Ward, R. D. (2009). Encyclopedia of sports speed: improving playing speed for sports competition. Kill Devil Hills, NC: National Association of Speed and Explosion ;.

Henricks, B. A Comparison of Strength Qualities and Their Influence on Sprint Acceleration. Journal of Australian Strength and Conditioning 22, 77-85. Retrieved August 3, 2014, from the Calu Manderino Library database.

 

Erin Hamlin

SPI Fitness is proud to announce that we will be the official strength and conditioning center for Erin Hamlin’s summer training!

SPI Fitness would like to thank Erin for being at our open house/grand opening at our location inside the Inertia Wellness Complex!

 

www.erinhamlin.com